Progress notes are also known as treatment notes, soap notes, daily notes, session notes—or even daily treatment notes!
Medicare Part B describes a treatment note as “a record of all treatments and skilled interventions that are provided…Documentation is required for every treatment day and every therapy service.”
In essence, a progress note (or whatever you want to call it!) is a record of your treatment session.
What We’ll Cover
What’s the Purpose of a Progress Note?
1. To record every speech therapy session
Your documentation tells the story of a patient’s episode of care.
Your patient first came into your orbit with a presenting illness. Maybe it was a stroke. Maybe it was an exacerbation of Parkinson’s disease. Either way, they were referred for a speech therapy assessment. The assessment results justified ongoing speech therapy, and you came in to fulfill the plan of care.
Your progress notes continue that story. Which interventions worked over the days, weeks, or months? How did the patient respond? Did they meet their goals?
Most funding sources rely on your notes and assessments to decide if skilled speech therapy is worth paying for. This brings us to the second purpose of Progress Notes:
2. To justify that the unique skills of a speech-language therapy professional were required during the session
Your progress note should prove to the funding source that your patient needed skilled speech therapy.
This means that you must clearly spell out the skilled services that you provided and why your patient needed them.
For example, let’s say that your progress note states “Treatment included conversation practice.” A funding source may conclude that they don’t need to pay you for conversation practice—this is something that a layperson could do with the patient.
Instead, you write “Therapist provided phrase-level expressive language treatment by having patient pair nouns with appropriate adjectives using prepared notecards.” Much better!
This skilled intervention:
1) works on the patient’s goal (which an earlier assessment proved was an area of weakness—or “need”—for this patient).
2) shows that you have the specialized skills that the patient needs in order to improve.
If you bill CPT codes, your note should also justify the CPT codes you billed and the number of units you billed. In other words, the interventions that you document should match the codes that you bill for that session.
Now, the third purpose of progress notes:
3) To stay focused on the plan of care, review how each session went, and plan for future session
Writing progress notes can help you to become a better practitioner.
They can remind you what you need to focus on. And they can help you understand what works for your patient—what doesn’t—and how to improve your plan each session.
What Actually Needs to go in a Progress Note?
What “needs” to go in a progress note is typically determined by the funding source. We’ll list the requirements of major funding sources in the U.S. (insurance companies and Medicare Part B). Be sure to know the requirements of the specific funding sources you work with.
1. Date of your Treatment Session
2. Total Treatment Time
Know each funding source’s guidelines for documenting time. If they don’t have guidelines, consider documenting total treatment time.
3. Each Intervention that you Provided and Billed for
Describe how you implemented the patient’s plan of care.
To do this, consider the patient’s goals:
- List the therapeutic tasks and activities that you did with the patient to work toward their goals.
- If appropriate, briefly describe the tasks and activities (see examples below)
- Be clear how each task/activity relates to their goals.
Include any patient or caregiver training that you provided.
Again, the intervention that you document should match the codes that you bill.
Progress Note Examples: Intervention
1) The therapist provided patient with 6 oz of thin liquids, training in use of safe swallowing strategies (including chin tuck and bolus hold), then had patient take small cup sips of the thin liquid using the safe swallowing strategies.
2) Therapist prepared a list of 50 /h/ initial words then reviewed voice strategies (including easy onsets). Patient practiced these voices strategies while reading the word list.
3) Therapist provided phrase-level expressive language treatment by having patient pair nouns with appropriate adjectives using prepared notecards.
4. Patient’s Response to Treatment
This is the data about the patient’s performance. It’s usually measured by accuracy or completion of the tasks.
Use objective data and consistent measurements.
For example, if you use percentage correct to measure progress towards a goal, always use percentage correct when working on that goal.
12/10/2022: The patient swallowed cup sips of thin liquids sans overt s/sx of aspiration in 70% of trials.
12/17/2022: The patient swallowed cup sips of thin liquids sans overt s/sx of aspiration in 80% of trials.
Include the patient and/or caregiver’s report of how the patient is progressing towards the goals.
Patient states that she remembered to take her medications 3 days this week.
Be clear about why the patient needs continued speech therapy.
Patient continues to demonstrate signs and symptoms of aspiration in 20% of trials and requires moderate assistance to utilize swallowing strategies.
Progress Note Examples: Response to Treatment
1) The patient drank 4 ounces of thin liquids sans overt s/sx of aspiration (e.g.,
coughing, wet vocal quality, etc.) in 80% of trials (8/10 sips). The patient accurately used safe swallowing strategies in 90% of opportunities (9/10 sips).
2) The patient completed a phrase-level expressive language treatment task at 80% accuracy (4/5 trials).
3) The patient used easy onsets in /h/ initial words at 84% accuracy (42/50 words). They reported using easy onsets about 50% of the time during conversational speech with spouse.
5. Cues You Provided
Include the types of cues you provided:
- Written, etc.
Include how much cueing you provided:
Include how often you provided cueing:
- Frequent, etc.
Be clear why each treatment required a skilled speech-language pathology professional present (versus a home exercise program). What specific skills did you provide for your patient?
- Tactile cueing to lip
- Visual modeling of mouth postures
- Skilled tactile verbal training, etc.
Progress Note Examples: Cueing
1) The patient drank 4 ounces of thin liquids sans overt s/sx of aspiration (e.g., coughing, wet vocal quality, etc.) in 80% of trials (8/10 sips). They accurately used safe swallowing strategies in 90% of opportunities (9/10 sips) given frequent minimal verbal cues and frequent visual cues (SLP modeled chin tuck, prompting, “Chin to chest”).
2) The patient completed a phrase-level expressive language treatment task at 80% accuracy (4/5 trials) given frequent moderate verbal cues.
3) The patient used easy onsets in /h/ initial words at 84% accuracy (42/50 words) given intermittent visual cues (SLP modeled large mouth opening and relaxed posture).
6. Ongoing Assessment of the Patient’s Progress Towards Their Goals
Summarize the patient’s progress towards their goals.
If relevant, include other patient factors impacting progress towards their goals:
- Patient’s emotional response to treatment
- Change in impairment
- Environmental influences
- Family support
- Caregiver schedule
- Sleep schedule, etc.
Progress Note Examples: Ongoing Assessment
1) Patient’s accuracy has steadily improved over the past 3 sessions. They will likely reach their goal by next week.
2) Patient’s accuracy appears to be negatively impacted by fatigue related to dialysis. Recommend scheduling ST before dialysis or after the patient naps.
7. Coordination with Care Team
Include any relevant coordination with the care team that you haven’t already noted.
This may include:
- Communication with the patient’s family or caregiver
- Communication or consultations with other disiplines (nursing, OT, PT, etc.)
- Outside referrals (nutritionist, ortolaryngologist, neurologist, etc.)
Progress Note Examples: Coordination with Care Team
1) SLP called and spoke with patient’s primary caregiver (daughter named Mei) and discussed progress and plan of care. Mei verbalized understanding and agreement to plan.
2) SLP left message with primary care provider to request status of order for modified barium swallowing study.
8) Plan of Care
Write a short description of next session’s plan:
- Name the tasks and activites you plan to use next session—”Continue plan of care,” is not specific enough.
- Include why your patient still needs your skilled intervention.
- If you change your plan of care, then describe what’s going to change and why.
Progress Note Examples: Plan of Care
1) Recommend continued dysphagia treatment with trials of thin liquids given the use of safe swallowing strategies.
2) Next session: Continue phrase-level expressive language tasks using notecards with nouns/adjectives to address continued expressive language deficit.
3) Continue practicing easy onsets with /h/ initial words. Trial /h/ initial multisyllabic words.
9) Therapist’s Signature and Credentials
Give yourself some credit!
More Popular Articles:
- How to Write Excellent Speech Therapy Goals
- The Complete Guide to Adult Speech Therapy Assessments
- Goal Bank for Adult Speech Therapy
Progress Note Template!
Below is a free PDF progress note checklist, just for you. Fyi, we used the term “Treatment Note” to align with Medicare.
For more Documentation Templates, check out The Adult Speech Therapy Starter Pack.